On July 22, Just Another Word Press.com site ran an article called Evolution not revolution: My thoughts on the DCP’s call for a paradigm shift. The website is owned and operated by MTAS Psychology, an agency providing psychological therapy and expert witness services in Manchester, UK. The article is unsigned.
The primary focus of the article is the paradigm shift paper issued on May 13, 2013 by the British Psychological Society’s Division of Clinical Psychology. That paper, as readers may remember, drew attention to “conceptual and empirical limitations” inherent in psychiatry’s so-called diagnostic system, and called for a paradigm shift – “towards a conceptual system not based on a ‘disease’ model.”
The author of the MTAS article expressed the belief that a paradigm shift of this sort is too extreme a step, and argues instead for an illness model that recognizes the importance of psychosocial factors.
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Here are some quotes, interspersed with my comments:
“I find myself in an almost constant state of conflicted ambivalence about this debate, most likely attributable to the unpleasant and unhelpful polarization that has taken place within the field in recent years…”
I view the polarization differently. For the past forty years, I have argued consistently that psychiatry’s central tenets are spurious, and their core practices destructive and disempowering. I have tried – and I know that others have tried – to engage psychiatrists in these discussions, but to no avail. Psychiatry steadfastly ignored all conflicting views, and continued on their mission to medicalize (spuriously) every conceivable problem of thinking, feeling, and/or behaving. For the past ten years or so, however, there has been a distinct turning of the tide. What the MTAS author describes as unpleasant and unhelpful polarization is nothing more than psychiatry’s opposition finding its voice and – finally – being heard. Some of the dialogue can at times be acrimonious, but the polarization in itself is neither unpleasant nor unhelpful. Rather, it is long overdue, and for most of us on this side of the debate, is welcome.
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“Maybe it’s a lack of vision on my behalf, but I can’t envisage a mental health system that does not involve medication and forced hospitalisation for clients at their most confused and distressed.”
Perhaps it is the author’s lack of vision. I have no difficulty whatsoever envisaging a system in which people struggling with problems of thinking, feeling, and/or behaving could go for help; where they would be listened to attentively and respectfully with no agenda of pigeon-holing them into spurious diagnostic categories; where they would be seen as individuals operating within a context; and where the entire message would be: you can!, rather than you’re broken, you can’t. Within my vision, psychiatrists have either ceased to exist as a profession or, more likely, operate in a shadowy world in which their activities would be seen for what they are – drug pushing. Their activities would be divorced from the genuinely helpful activity mentioned earlier, for the simple reason that genuine care-givers will refuse to work with them. Clients who wanted drugs would go to the psychiatrists; client who wanted help in finding genuine solutions to life’s problems would go to psychosocial helpers.
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“I think a symptom/experience based focus could further our understanding of certain presentations, particularly when we remember that a proportion of people satisfying the criteria for a diagnostic category will not represent the archetype, and will sometimes have quite divergent experiences from one another.”
There is no archetype. And the people embraced by any psychiatric “diagnosis” will always have gotten to the point they are by different routes, and they will always have very different experiences. This is the essence of the matter. Psychiatry’s so-called diagnostic system does indeed imply archetypes, but it’s all a fabrication. Psychiatrists “see” these archetypes because they invented them, and they have become the distorting lens through which they view their clients. The archetypes have no ontological reality.
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“…any symptom/experience based approach to research would have to include some system for organising participants into meaningful groups.”
This statement is simply false. Much, perhaps most, research done in the behavior therapy/behavioral analysis field, for instance, is of the before-after, single-case design, where the object of the endeavor is to understand the dynamics of the situation, and to develop appropriate interventions. Psychiatrists, by contrast, routinely pretend (or perhaps have even convinced themselves) that they achieve understanding of a client’s perspective by assigning him a label. Consider the hypothetical conversation:
Client: Why am I so depressed?
Psychiatrist: Because you have an illness called major depression.
Client: How do you know that I have this illness.
Psychiatrist: Because you are so depressed.
This is the essence of psychiatric diagnosis: a futile exercise in circular reasoning, whose only purpose is the justification of a prescription for psychotropic drugs. The use of these spurious categories in psychiatric research is not only unnecessary, but actually introduces a huge measure of invalidity into the results.
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“Lumping all of these people together could be problematic for conducting reliable research, but separating them up is, essentially, just another way of categorising people.”
Research that uses unreliable grouping criteria, not only could be problematic, it is problematic. And generalizing from such research is also problematic, but sadly is the norm in psychiatry.
Separating people up (i.e. treating them as individuals) is not just another way of categorizing people. In fact, it is the opposite of categorizing people.
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“I just can’t conceptualise how one might start to meaningfully organise clients’ difficulties without using categories or groups.”
I think there are a number of problems here. Firstly, I don’t believe that most clients want, or need, to have their difficulties organized. I can accept that a small minority of clients are confused and might appreciate some assistance with organizing matters, but, in my experience, the great majority of clients are able to express and explain their problem(s) clearly and unambiguously. Secondly, and, more importantly, even if a person does need help organizing his difficulties, slotting these difficulties into arbitrarily defined and unreliable pigeon-holes is unlikely to be helpful, and is more likely to be seen as patronizing and condescending. If a client states that he worries a great deal about all sorts of things, what possible value is provided by my telling him that he “has” generalized anxiety disorder?
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“In saying all of this, DSM 5 was an omni-shambles and there is surely a more scientifically sound way of organising the presenting problems of service-users. I am all for developing new, more robust systems, but calling for a wholesale ‘paradigm shift’, when a workable alternative has not yet been developed, never mind validated, is a bit of a misstep in my opinion.”
But there is a working alternative: listen to what the client says; ask clarificatory questions as needed; listen to the client’s responses; discuss; help the client mobilize his strengths to alleviate his difficulties; coach; support, etc., as needed. But above all, listen respectfully. This is not the medical model, but it’s what’s needed.
Besides, what possible use can there be in categorizing people’s presenting problems with a framework that the author acknowledges is an “omni-shambles”? The development of “…a more scientifically sound way of organizing the presenting problems of service users…” has been psychiatry’s stated goal for six decades. But in this regard, DSM-5 is no better than DSM-I (1952); and in many respects is a great deal worse! Perhaps it’s time to acknowledge that people’s problems of thinking, feeling, and/or behaving are too individualized and too context-specific, to lend themselves to any kind of simplistic, pseudo-medical categorization. Perhaps it’s time to acknowledge that slotting people and their problems into categories, whilst perhaps conferring some sense of control and efficacy to the practitioner, affords no benefit, and a good deal of harm, to the client.
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“I really don’t see why the two approaches must be mutually exclusive. One of the therapy models I practice is Interpersonal Psychotherapy (IPT). It takes the approach that depression is an illness.”
The word “illness” means a functional or structural pathology within the organism. Depression is not an illness, and any attempt to treat it as such is deceptive, unhelpful, and ultimately disempowering.
And the two approaches must indeed be mutually exclusive, because treating depression as an illness is simply incompatible with treating depression as the normal human response to loss, other adverse events, or a meaningless, treadmill kind of existence.
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“Personally I despise the name BPD [borderline personality disorder], but, at the same time, certainly see the value in having a group or category that captures the kind of difficulties often experienced by this group of clients.”
The author is missing the point. A spurious category by another name is still a spurious category. Even groups that reflect very simple categorization criteria are extremely heterogeneous. The eleven members on a soccer team could all be categorized as soccer players, but their outlook and motivation will inevitably differ enormously. One person may be there for exercise; another to please his parents; another to aggravate his parents; another to show off to his girlfriend; etc… For some, soccer is a lifelong passion, for others a passing whim. How much more divergence will there be with DSM’s intrinsically unreliable criteria for the condition labeled borderline personality disorder, e.g.:
1. Frantic efforts to avoid real or imagined abandonment.
At what point does an effort become a frantic effort? No distinction is made between efforts that involve sending lots of emails, for instance, vs. kidnapping and physical confinement. How do we assess “imagined” abandonment?, etc…
2. A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation.
How do we define relationship instability – two break-ups in a year? Three? Five? How do we define, or even begin to measure, the intensity of a relationship? And “alternating extremes of idealization and devaluation” – how do we distinguish this from the ebbs and flows of “normal” relationships? Does anyone seriously imagine that a criterion worded in this way is capable of consistent application?
3. Identity disturbance: markedly and persistently unstable self-image or sense of self.
What does “identity disturbance” mean? Doesn’t everyone’s self-image fluctuate and change over time? How do we assess “markedly” and “persistently”? And what in the world is “sense of self”? And DSM-5 is not helpful: “Although they usually have a self-image that is based on being bad or evil, individuals with this disorder may at times have feelings that they do not exist at all.”
And so on for the other six criteria.
And remember, even if we manage to make any headway with the individual criteria, the “diagnosis” is considered positive if five or more of the nine criteria are met. From high school math we know that there are 256 ways to select five or more items from nine. So “borderline personality disorder” subsumes at least that number of specific presentations.
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“…as psychologists I think we use categories all the time.”
I would say: as psychologists we understand, or at least ought to understand, the conceptual limitations of categorizing people, or people’s thoughts, feelings, or behavior. We also recognize the damage done by “diagnostic” categories in terms of stigmatization and reduced expectations, and we generally confine our interest and our attention to specific behaviors that can be reliably identified and discussed meaningfully.
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“Whilst I share some of my colleagues’ concerns regarding the relative dominance of a medical model for understanding human suffering, I think both can exist together, at the same time.”
To which I can only respond that the past 60 years of psychiatric hegemony suggests otherwise. During this time, psychiatry has relentlessly promoted its spurious medicalization of all forms of human distress and has routinely marginalized and even ridiculed its critics. It has developed a system that is simply incompatible with the conceptual framework employed by the great majority of social workers, counselors, psychologists, job coaches, etc… Here in the US, childhood temper tantrums are now a mental illness, and we have toddlers as young as two years old being prescribed neuroleptic drugs! What room is there in such a system for a context-sensitive, psychosocial approach?
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“A combination of perspectives is always favourable, surely?”
Compromise, and a combination of perspectives, are sometimes favorable. Other times – as in the present matter – they are not. Surely! What kind of theory of fire would chemists have today, for instance, if the oxygenation proponents had compromised with the phlogiston theory adherents? Some conceptual frameworks are just plain wrong, and need to be scrapped. Psychiatry has been intellectually bankrupt for most of its history, particularly for the past fifty years. At the present time it is being maintained on life-support by pharma money.
CONCLUSION
For the past ten or fifteen years valid criticisms have been directed at psychiatry’s “diagnostic” system, and at its range of treatments. Psychiatry has not only ignored these criticisms, but has actually accelerated its medicalization agenda, and has asserted the putative efficacy of its treatments with increased vigor. There has been no slowing down of the psychiatric juggernaut, and apart from the efforts of a small number of psychiatrists, there has been no indication that basic concepts or practices are being reconsidered, or re-evaluated in any way.
The human toll, in terms of ongoing damage, disempowerment, and stigmatization, is enormous, and continues to grow.
There is, in my view, no possibility that a system led by psychiatrists will ever become truly helpful in the alleviation of problems of thinking, feeling, and/or behaving. There is an urgent need for a paradigm shift, and the BPS’s clinical division is to be commended for taking this initiative. There is an urgent need to develop an alternative system, based, not on the notion that people are broken and need chemical adjustment, but rather on the notion that, with help, people can resolve their problems and find some peace and contentment. The notion that such a system can develop and thrive under a psychiatric roof is simply unrealistic.